Provider Demographics
NPI:1699986521
Name:WAGNER, NANCY J (MD)
Entity type:Individual
Prefix:DR
First Name:NANCY
Middle Name:J
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 MEADOWCREST ST
Mailing Address - Street 2:STE A
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70056
Mailing Address - Country:US
Mailing Address - Phone:504-392-1618
Mailing Address - Fax:504-392-1813
Practice Address - Street 1:151 MEADOWCREST ST
Practice Address - Street 2:STE A
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056-5256
Practice Address - Country:US
Practice Address - Phone:504-392-1618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA104904207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1321966Medicaid
B61273Medicare UPIN
LA5J831Medicare ID - Type Unspecified